Hypertensive Crisis Exam 2

Hypertensive Crisis

- An emergency

- Defined as a severe increase in BP (Commonly) above 180/120 mm Hg

- Anytime there is excessive hypertension (vaso constriction) it constricts the organs and it can lead to Myocardial infarction, Ischemic stroke, Hemorrhagic stroke, Pulmonary edema, or Kidney failure

- The goal is to decrease the risk or damage to the organs

Common Causes of Hypertensive Crisis

1. Non-adherence to medication regime

2. May have been under medicated

3. Rapidly increasing BP

4. Acute Aortic Dissection

5. Pheochromocytoma

6. Drugs

7. Pregnancy Complications

Non-adherence to medication regime

due to dementia, being forgetful, unable to swallow, being too expensive, people ignorant to the fact since they don't feel it, or interference with libido

May have been under medicated

Due to Weight gain, not going to the doctors, no follow ups, not doing yearly physical, or diet adjustments

Rapidly increasing BP

can cause shearing of the endothelial surface due to turbulent blood flow within the vessel

Acute Aortic Dissection

Aneurysm

Pheochromocytoma

Endocrine issue, rare, tumor in the adrenal gland releasing extra stress hormone

Drugs

Crack/ cocaine, amphetamines, phencyclidine (PCP), and lysergic acid diethylamide (LSD)

Pregnancy Complications

Preeclampsia, eclampsia

Manifestations of Hypertensive Crisis

1. Hypertensive encephalopathy

2. Renal insufficiency

3. Rapid cardiac decompensation

Hypertensive encephalopathy

- Severe headache, nosebleeds, nausea, vomiting, seizures, confusion, and coma

- Permeability and leaking out of the edema can occur causing a lot of pressure to the eyes and cause a stroke

Renal insufficiency

- Starts as minor injury and progressives to complete renal injury

- The kidney is not getting the blood it is supposed to be getting

- Tests: BUN, Creatinine, GFR, electrolytes, 24 hour urine sample, intake and output, or hourly output (30mL)

Rapid cardiac decompensation

- Caused from unstable angina, to MI, and pulmonary edema

- Symptoms: Chest pain, dyspnea, sudden severe chest pain, back pain, with reduced or absent pulses in extremities

Management of Care of Hypertensive Crisis

- Requires hospitalization

- Two large bore intravenous (IV) lines

- Administration of antihypertensive medications

- Intensive monitoring

- Careful assessment of target organ disease

- Make sure the first thing you give the patient is oxygen and check pulse ox

- Monitor vital signs every 5 minutes to monitor blood pressure

- Goal is to stable the blood pressure not drop the blood pressure because it can cause a heart attack, angina, MI, or stroke

Careful assessment of target organ disease

Determines the seriousness of the situation and outcome: Check if patient can answer neural questions, make sure all their pulse points are there, lab tests, intake and output, and make sure there is no chest pain

MAP hypertensive crisis

- Monitor MAP (mean arterial pressure) 70-110

- The MAP score stands for the organ viability

- Goal is to decrease the MAP by no more than 20% to 25% to 110 - 115 mm HG over 24 hours

- Lowering the BP too quickly may decrease cerebral, coronary, or renal perfusion

- A rapid decrease could cause a stroke, MI or renal failure

MAP Math

MAP = (SBP +2(DBP) / 3

Interventions for Hypertensive Crisis

- Obtain baseline VS, including oxygen saturations

- Start continuous BP and ECG monitoring

- Insert 2 large bore IV's: For multiple medications in case they can't mix or something occurs that access is needed

- Strict Intake and output

- Administer IV antihypertensive medications as ordered (sodium Nitroprusside)

- Obtain base line blood work

- Administer oxygen

- Arterial line: Used to continuously monitor blood pressure

Medication management for Hypertensive Crisis

1. Vasodilators

2. Adrenergic inhibitors

3. Calcium channel blocker (CCB)

4. Beta Blockers

Vasodilators

- Nicardipine and sodium nitroprusside (dilator)

- Wait 5 minutes before titrating (increasing the dose)

- Causes afterload to decrease

- Doctors will always use short term or short acting hypertensives when it is going through an IV

Side effect of sodium nitroprusside

Cyanide toxicity

Adrenergic inhibitors

- Phentolamine, labetalol, esmolol:

- Small doses, 80 mg undilated push or put in the IV bag as a drip

Calcium channel blocker (CCB)

- Clevidipine (Cleviprex)

- Given as IV

Beta Blockers

- Selective, non selective, and alpha 1

- Beta 1: Sympathetic Nervous System, for the heart. Metoprolol, Atenolol, Propranolol, Tenolol

- Beta 2: Affects the lungs. Propranolol, Tenolol

- Beta 3: Alpha blocking action and widens the blood vessels (decreases blood pressure)

- Beta 1 with alpha 1 blocking: Peridol, Coreg, Labetalol

- NEVER stop IV hypertensives abruptly because it can cause heart failure or angina

Tenolol

Given as an eye drop for glaucomaAdminister in the center of the eye

Ongoing monitoring for Hypertensive Crisis

- Monitor vital signs

- Level of consciousness: Don't want to bring BP down too much

- Heart sounds, breath sounds, heart rhythm, oxygen saturation

- Measure urine output hourly: Checking the kidneys

- Maintain bedrest

- Provide reassurance and emotional support

- Explain all interventions

- Side effects to medications

Cardiac Output

- Amount of blood ejected from Left ventricle /q min

- HR/ min X stroke volume/liter

- Results depend on the size of the heart & how fast it contracts

Heart Rate

- Amount of heartbeats/min

- Normal range = 60-100 ml/beat (average is 70ml/beat)

Stroke volume

- The amount of blood pumped out by the ventricle of the heart during a single heartbeat

Dopamine

Increase heart work and raises the blood pressure

Digoxin with Beta Blocker

Before giving digoxin with a beta blocker heart rate should be measured through the apical and greater then 60

Medications that Improve Cardiac Output

- Positive inotropic = Increase myocardial contractility and systemic vascular resistance (SVR): Dopamine, Dobutamine, Levophed (short term), Digoxin

-Vasodilators (if not hypotensive): IV Nitroglycerine, Morphine, Sodium Nitroprusside

Preload

The stretch of the heart and the amount of blood the volume of blood received by the heart

Afterload

When there is an increase in afterload it makes the heart work more due to the resistance